颈内动脉接近完全闭塞时的处理

目的由于卒中风险随着狭窄严重程度的增加而升高，因此认为颈内动脉（ICA）接近闭塞患者的卒中风险很高。在现有的随机试验中，还没有专门针对这种情况进行探讨，因此其处理尚存在争汶。方法：对相关文献进行系统评价。结果：对ICA接近闭塞患者的处理还存在争议：一些学者支持进行干预，而另一些学者则认为存在风险或没有益处而反对进行干预。在ICA接近闭塞的有症状患者中进行一项比较外科治疗与最佳内科治疗的多中心前瞻性随机试验似乎非常困难，因为这类研究需要大量的患者。尽管如此，基于目前的证据，似乎很难拒绝手术治疗。结论：由于目前对ICA接近闭塞患者的最佳处理方案仍存在着争议，因此需要前瞻性观察性研究以证实其在有症状和无症状人群中的患病率以及相关的卒中风险。基于目前的证据，大多数医疗中心选择手术治疗，但它相对干内科治疗的特粱尚右待证章．     

ENACTMENT: SOME THOUGHTS ABOUT THE THERAPIST'S CONTRIBUTION

ABSTRACT This paper examines three instances of enactment, which occurred in the early stages of a thrice-weekly therapy. The emphasis is on both the origins and consequences of the therapist's contribution. Particular attention is paid to the unconscious nature of enactment, as a phenomenon that can precipitate both a refusal and an actualization of the patient's transference; the former, in this case, leading to further acting out and the latter to malignant regression.     

Therapy associated leukaemia.

A dose related risk of acute leukaemia, myelodysplasia and other cancers is seen in patients treated with certain drugs, particularly alkylating agents, and radiotherapy either alone or in combination. Treatment associated acute myeloid leukaemia (tAML) and myelodysplasia have biological and clinical features in common and are distinct from the corresponding de-novo disorders. tAML generally occurs between 2-11 years from administration of chemo/radiotherapy with few cases thereafter. Patients may present with myelodysplasia and severe cytopenia with abnormalities in all cell lines or as an acute leukaemia which may be difficult to classify because of multi-lineage involvement. Clonal cytogenetic abnormalities usually including either loss or interstitial deletion of the long arm of chromosomes 5 or 7 are frequently identified. Critical regions deleted in all patients with these lesions have been localised at 5q23-32 and 7q22-31; regions carrying the genes for several haemopoietic growth factors, receptors and oncogenes. The prognosis of patients with tAML is poor with low remission rates and a median survival of 6 months. Complex karyotypes or lesions of chromosomes 5 or 7 seen in the majority of cases are associated with a particularly poor outlook. The risks of this most serious complication of therapy should be weighed carefully against possible benefits.     

The favoured child?

This case conference concerns a child who has been in care following a diagnosis of emotional abuse and a serious incident of physical abuse. She wants to return home again, and her parents, who had previously scapegoated her, now blame the family''s previous ills on her sister instead. The Children Act 1989 gives considerable weight to the child''s wishes, but what if the child returns home and is re-abused? In this case conference a child psychiatrist, a philosopher and a lawyer discuss the issues of clinicians'' responsibilities, moral luck, and child care law.